Clinical features of prolonged tilt-induced hypotension with an apparent vasovagal mechanism, but without syncope.

BACKGROUND: A previous study of electroencephalography (EEG) changes with syncope led to a finding that some young patients develop prolonged periods of tilt-induced hypotension, but they do not lose consciousness. The present study aim was to compare patterns of hemodynamic changes, measures of duration, and sweating between these patients and patients with tilt-induced vasovagal syncope. METHODS: In an observational study, qualitative changes in hemodynamic parameters were compared between patients with prolonged hypotension (n = 30) and with syncope (n = 30). To demonstrate that periods of hypotension far-exceed the typical presyncope period, several parameters were used to compare the durations of events between groups. Differences in sweating patterns were explored. RESULTS: Parallels in hemodynamic changes were present in both groups suggesting similar vasovagal mechanisms. Patients with prolonged hypotension had longer durations of hypotension (165 ±â€¯44 versus 57 ±â€¯13 s, p < 0.001), diminished cardiac output (109 ±â€¯38 versus 32 ±â€¯9 s, p < 0.001), and EEG slowing (85 ±â€¯31 versus 9 ±â€¯4 s, p < 0.001) compared to patients with syncope. While all patients generated an increase in sweat rate, those with hypotension only developed a robust sweat response that always preceded the plateau in hypotension compared to 14 (47%) patients with syncope who developed an increase in sweating prior to syncope, p < 0.001. CONCLUSIONS: Similarities are present among hemodynamic changes with prolonged hypotension and with tilt-induced vasovagal syncope, suggesting a possible vasovagal mechanism for prolonged hypotension. If true, understanding why some individuals develop a vasovagal response that does not culminate in rapid syncope may help to elucidate the physiologic underpinnings of the vasovagal reflex.

The Fainting Assessment Inventory: A 10-Item Instrument Developed to Screen for Psychogenic Nonsyncopal Collapse Among Youth Referred for Syncope.

The conversion disorder that appears like syncope is common but poorly recognized. The study aimed to develop and validate a brief, clinician-administered screening tool to discriminate psychogenic nonsyncopal collapse (PNSC) among young patients referred for fainting. Consecutive patients with PNSC and with syncope (15.4 ± 2.2 years) completed a 92-item inventory highlighting features typical of PNSC and neurally mediated syncope (n = 35, each cohort). Fourteen items were retained and revised and then administered to new cohorts ultimately diagnosed with PNSC or syncope (n = 40, each cohort). Further revision led to a 10-item Fainting Assessment Inventory (FAI-10). Scoring the syncope ratings positively and the PNSC ratings negatively, median scores differed between cohorts with PNSC and with syncope (-6 vs. 7; p < 0.001). Diagnostic sensitivity (0.95), specificity (0.875), positive predictive value (0.889), negative predictive value (0.93), and area under the curve (0.973) were calculated. The FAI-10 furthers clinicians' ability to distinguish various forms of transient loss of consciousness.

Atypical Prodromal Symptoms Help to Distinguish Patients With Psychogenic Nonsyncopal Collapse Among Youth Referred for Fainting.

BACKGROUND: Distinguishing patients with psychogenic nonsyncopal collapse (PNSC), a conversion disorder that resembles syncope, can pose a difficult clinical challenge. Using the open-ended question "what does it feel like to faint?," the present study aimed to characterize how patients with PNSC perceive and communicate the prodromal symptoms associated with their attacks by comparing narratives between patients with PNSC and those with syncope. METHODS: During a 42-month database-type study of tilt-table diagnoses, all patients with a history of fainting were asked the open-ended question. Symptom descriptions were compared, qualitatively and quantitatively, between patients with PNSC and those with tilt-induced syncope (n = 121 in both cohorts). RESULTS: Twenty-nine patients (24%) diagnosed with PNSC and eight (6.6%) diagnosed with syncope either denied having any prodromal symptoms or could not recall any symptoms (P < 0.001). Among patients who reported prodromal symptoms, patient narratives led to the formation of 26 symptom categories. Symptom frequencies differed between cohorts in 19 of the symptom categories (each P value <0.05). Qualitative differences in the descriptions of symptoms were often present, even when symptom frequencies did not differ. More patients with PNSC described atypical symptoms than patients with syncope, 54 of 92 (58.7%) versus eight of 113 (7.1%), P < 0.001. CONCLUSIONS: Symptom narratives can help to distinguish patients with PNSC from those with syncope. The use of a single, open-ended question as a screening tool for conversion disorder has immediate clinical relevance because it can be instituted easily in a busy clinical setting.

Quantitative electroencephalography characteristics of tilt-induced neurally-mediated syncope among youth.

OBJECTIVE: To characterize the quantitative electroencephalographic (QEEG) patterns associated with tilt-induced syncope in youth. METHODS: Several QEEG parameters were analyzed. Data were calculated for peak or nadir changes with syncope for amplitude-EEG, fast Fourier transform (FFT) power in several frequency ranges, 8-13 Hz/1-4 Hz frequency ratio, and FFT edge. RESULTS: Changes in QEEG parameters were present among all patients with tilt-induced syncope (n = 76). These changes included increases in the low frequency FFT power (1-4 Hz range), decreases in the power ratio (8-13 Hz/1-4 Hz) and decreases in the FFT edge (95%, 1-18 Hz). All patients had suppression of EEG amplitudes that closely followed loss of consciousness. Asymmetry indices demonstrated cerebral hemisphere lateralization at multiple periods during the evolution of syncope, but the side of lateralization did not differ from 0.5 probability. CONCLUSIONS: QEEG parameters can be used to characterize EEG changes associated with tilt-induced, neurally-mediated syncope. SIGNIFICANCE: QEEG may serve as a useful tool for the study of syncope neurophysiology, and the modeling of changes with syncope may improve our understanding of other neurologic disorders caused by defects in cerebral perfusion.

Signs of autonomic arousal precede tilt-induced psychogenic nonsyncopal collapse among youth.

Characterizing the physiologic changes leading up to psychogenic nonsyncopal collapse (PNSC) may help to elucidate the processes that cause paroxysmal functional neurological symptom disorders and to clinically distinguish PNSC from syncope. Thus, we aimed to characterize preictal sweat rate, heart rate, and systolic blood pressure changes among patients with tilt-induced PNSC compared to patients with tilt-induced neurally mediated syncope. The presence of increased preictal sweating was compared between groups. Heart rates and systolic blood pressures were compared from the recumbent and tilted baselines to the periods 120 s and 30 s prior to PNSC and syncope. Patients with PNSC (n = 44) were more likely than patients with syncope (n = 44) to have preictal increases in sweating, n = 31 (70.5%) versus n = 21 (47.7%), p = 0.03, although all patients with syncope eventually developed a sweat response. Comparing the recumbent baseline to the period 30 s prior to PNSC, blood pressure (112 ±â€¯9 versus 129 ±â€¯13 mmHg, p < 0.001) and heart rate (76 ±â€¯12 versus 119 ±â€¯22 bpm, p < 0.001) increased. Similarly, comparing the tilted baseline to the period 30 s prior to PNSC, blood pressure (118 ±â€¯12 versus 129 ±â€¯13 mmHg, p < 0.001) and heart rate (95 ±â€¯15 versus 119 ±â€¯22 bpm, p < 0.001) increased. Preictal blood pressure and heart rate differed significantly between patients with PNSC and patients with syncope. In conclusion, signs of autonomic arousal (increased sweating, heart rate, and blood pressure) often precede tilt-induced PNSC. Sweating prior to fainting may not be useful in distinguishing PNSC from neurally mediated syncope.

Early outcomes in youth with psychogenic nonsyncopal collapse.

OBJECTIVE: To evaluate several early outcome measures following diagnosis of psychogenic nonsyncopal collapse (PNSC). METHODS: Over a 34-month period, a prospective cohort study was conducted of patients referred for tilt-table evaluation of fainting and orthostatic intolerance. Clinical histories were obtained and anxiety and depressive symptom questionnaires were completed prior to testing. Among 539 patients referred, 100 (18.6%) were diagnosed with PNSC. Outcome data were collected by telephone or during routine follow-up a median of 572 days postdiagnosis. RESULTS: Eighty-four patients (84%) provided outcome data. Following communication of the diagnosis, 32 patients (38%) had immediate PNSC resolution. Attack resolution occurred in 44% by 1 month, 51% by 6 months, 52% by 12 months, 69% after 12 months, and 31% continued to have PNSC at the time of follow-up. Patients with continued PNSC had higher anxiety scores than patients with immediate resolution (p = 0.047). Following diagnosis, emergency department visits for fainting decreased from 78.6% to 20.2% (p = 0.017), and management by psychology or psychiatry increased from 26.2% to 76.2% (p < 0.001). During the follow-up period, 8 patients (9.5%) were hospitalized for suicidal ideation, a median of 253 (range 33-470) days postdiagnosis; 12 patients (14.3%) developed new (non-PNSC) conversion disorders, a median of 86 (range 9-504) days postdiagnosis. Suicidal ideation was associated with higher anxiety (p = 0.007) but not higher depression scores. CONCLUSIONS: The diagnostic rate of PNSC parallels that of PNES among patients referred for tertiary care evaluations. The improvements in attack frequency following PNSC diagnosis must be tempered by the potential risks of self-harm and the development of new conversion disorders.

Pediatric Disorders of Orthostatic Intolerance.

Orthostatic intolerance (OI), having difficulty tolerating an upright posture because of symptoms or signs that abate when returned to supine, is common in pediatrics. For example, ∼40% of people faint during their lives, half of whom faint during adolescence, and the peak age for first faint is 15 years. Because of this, we describe the most common forms of OI in pediatrics and distinguish between chronic and acute OI. These common forms of OI include initial orthostatic hypotension (which is a frequently seen benign condition in youngsters), true orthostatic hypotension (both neurogenic and nonneurogenic), vasovagal syncope, and postural tachycardia syndrome. We also describe the influences of chronic bed rest and rapid weight loss as aggravating factors and causes of OI. Presenting signs and symptoms are discussed as well as patient evaluation and testing modalities. Putative causes of OI, such as gravitational and exercise deconditioning, immune-mediated disease, mast cell activation, and central hypovolemia, are described as well as frequent comorbidities, such as joint hypermobility, anxiety, and gastrointestinal issues. The medical management of OI is considered, which includes both nonpharmacologic and pharmacologic approaches. Finally, we discuss the prognosis and long-term implications of OI and indicate future directions for research and patient management.

Youth With Psychogenic Non-Syncopal Collapse Have More Somatic and Psychiatric Symptoms and Lower Perceptions of Peer Relationships Than Youth With Syncope.

BACKGROUND: Little is known about somatic and psychiatric symptoms and perceived peer relationships of patients with psychogenic nonsyncopal collapse. OBJECTIVE: This study aimed to compare somatic and psychiatric symptoms and other elements potentially related to functional neurological symptom disorders between youth with psychogenic nonsyncopal collapse and those with neurally mediated syncope. METHODS: Before testing, patients completed a structured interview and questionnaire addressing current symptoms, previous psychiatric diagnoses, referrals, diagnostic testing, prescribed medications, and patient self-ratings of anxiety, depression, and perceived peer relationships. RESULTS: Compared with patients with syncope (n = 60), patients with psychogenic nonsyncopal collapse (n = 60) had higher ratings for lightheadedness and vertigo, more abdominal pain, more chronic headaches, more fatigue, more sleep disturbances, more prescriptions for antidepressant medicines, more encephalograms performed, more referrals to psychiatry, and more psychiatric diagnoses including anxiety, depression, posttraumatic stress disorder, previous nonfainting conversion disorders, and eating disorders (all p < 0.05). Patients with psychogenic nonsyncopal collapse rated their anxiety (10.5 ± 7.7 versus 5.9 ± 5.8, p < 0.001) and depression (8.7 ± 8.3 versus 3.1 ± 5, p < 0.001) symptoms higher and their peer relationships (37 ± 12.3 versus 47.6 ± 7.9, p < 0.001) lower than patients with syncope. Peer relationships remained significantly lower (p = 0.001) when analyzed with anxiety and depression. CONCLUSION: Patients with psychogenic nonsyncopal collapse have more symptom complaints and perceptions of poorer peer social interactions than patients with syncope. These results broaden our understanding of the biopsychosocial profile that increases an individual's vulnerability to psychogenic nonsyncopal collapse specifically and to functional neurological symptom disorders in general.

Lightheadedness After Concussion: Not All Dizziness is Vertigo.

OBJECTIVE: To characterize the presence and degree of postconcussion lightheadedness in relation to postconcussion vertigo and dizziness, and to determine whether lightheadedness influences overall symptom duration. DESIGN: Prospective, cohort design. SETTING: Nationwide Children's Hospital, Sports Concussion Clinic. PARTICIPANTS: Five hundred ten patients (9-19 years of age) within 30 days of concussion injury. MAIN OUTCOME MEASURES: Patient ratings (scale 0-6) of multiple postconcussion symptoms including lightheadedness, vertigo, and dizziness, reported from the day of clinic evaluation and recalled from the day of concussion. RESULTS: Postconcussion lightheadedness occurred commonly relative to vertigo. Lightheadedness was recalled more than vertigo (70.8% vs 48.6%, P < 0.001) on concussion day and reported more than vertigo (47.1% vs 24.1%, P < 0.001) on the day of clinic evaluation. Principal component analysis demonstrated strong correlations among lightheadedness, vertigo, balance difficulties, difficulty concentrating, mental fogginess, and difficulty remembering, relative to other postconcussion symptoms. When present on the day of clinic evaluation, these highly correlated symptoms predicted prolonged concussion recovery [P = 0.028; Hazard Ratio (HR) = 1.2]. Female sex (P = 0.04; HR = 1.23), emotional symptoms recalled from the day of concussion (P = 0.007; HR = 1.23), and cephalalgic symptoms (P < 0.001; HR = 1.34) reported on the day of clinic evaluation also predicted prolonged concussion recovery. CONCLUSIONS: Not all postconcussion dizziness is vertigo. Postconcussion lightheadedness is common and, when present at the time of clinic evaluation, can influence concussion recovery. CLINICAL RELEVANCE: Distinguishing postconcussion lightheadedness from vertigo may help to inform clinical treatment and concussion research design. This study adds to the growing body of evidence that supports an association between concussion and autonomic dysfunction.

Postural Tachycardia Syndrome: Diagnosis and Management in Adolescents and Young Adults.

Postural tachycardia syndrome (POTS) represents a common form of orthostatic intolerance that disproportionately affects young women from puberty through adulthood. Patients with POTS have day-to-day orthostatic symptoms with the hallmark feature of an excessive, sustained, and symptomatic rise in heart rate during orthostatic testing. Although considerable overlap exists, three subtypes of POTS have been described: neuropathic, hyperadrenergic, and hypovolemic forms. The wide spectrum of symptoms and comorbidities can make treatment particularly challenging. Volume expansion with fluid and salt, exercise, and education constitute a reasonable initial therapy for most patients. Several medicines are also available to treat orthostatic intolerance and the associated comorbidities. Defining the POTS subtypes clinically in each patient may help to guide medicine choices. A multidisciplinary approach to overall management of the patient with POTS is advised. This review highlights several aspects of POTS with a specific focus on adolescent and young adult patients. [Pediatr Ann. 2017;46(4):e145-e154.].

Comparison of Specific Fainting Characteristics Between Youth With Tilt-Induced Psychogenic Nonsyncopal Collapse Versus Reflex Syncope.

Little is known about the predictive features of psychogenic nonsyncopal collapse (PNSC). The aim of the present study was to compare the self-reported fainting characteristics between young patients who were ultimately diagnosed with PNSC with those ultimately diagnosed with neurally mediated syncope and to determine which features were predictive of either diagnosis. A prospective study was conducted of sequential patients referred for fainting. All study data were obtained before testing or diagnosis. Several fainting characteristics were compared between cohorts including numbers of lifetime fainting episodes, fainting frequency the week before evaluation, fainting duration, numbers of fainting spells in a single day, presence of presyncope, types of prodromal symptoms, tearfulness with fainting, and the numbers of emergency department visits and hospital admission for fainting. During the study period, 52 patients were diagnosed with PNSC, producing a diagnostic rate of 18.9%. In univariate analyses, multiple features differed between patients with PNSC and those with syncope. After controlling for age and gender in a multivariate analysis, each of the following predicted PNSC: ≥20 lifetime fainting spells (p = 0.005), ≥2 fainting spells in a single day (p = 0.03), self-reported loss of consciousness ≥2 minutes (p = 0.01), and tearfulness associated with fainting (p = 0.022). Two or more typical prodromal symptoms (p = 0.004) predicted syncope. In conclusion, several characteristics related to fainting have predictive value in distinguishing PNSC from syncope, particularly among youth. Assessing these clinical features can help to inform appropriate testing and accurate diagnosis among patients who faint.

Utilization of conventional neuroimaging following youth concussion.

BACKGROUND/OBJECTIVE: Conventional neuroimaging is not recommended for the routine diagnosis of concussion, but some patients with concussion undergo computed tomography (CT) or magnetic resonance imaging (MRI). The objective of this study was to explore the clinical factors that predict neuroimaging utilization in concussion. METHODS: Concussion-related CT and MRI data were analysed from 1953 patients, aged 10-19 years, who presented to a sports concussion clinic within 30 days of injury. RESULTS: The majority of CT scans (n = 193) were obtained during the acute concussion period (mean = 2.7 days post-concussion), whereas MRI scans (n = 134) were ordered later during recovery (mean = 39.4 days post-concussion). Predictors of CT utilization included loss of consciousness, amnesia and vomiting (all p < 0.001). Prior concussion (p = 0.002) and continued participation in activity after injury (p = 0.03) predicted greater MRI utilization. Neuroimaging with either CT (p = 0.024, hazard ratio = 1.2) or MRI (p < 0.001, hazard ratio = 2.75) was associated with prolonged symptoms. Only 3.1% of CTs and 1.5% of MRIs demonstrated signs of traumatic brain injury. CONCLUSION: Several clinical factors predict neuroimaging utilization in patients with concussion. CT is generally used acutely, while MRI is used in the sub-acute and chronic post-concussion periods. In a sports concussion clinic, delayed neuroimaging has limited clinical yield.

Comparison of semiologies between tilt-induced psychogenic nonsyncopal collapse and psychogenic nonepileptic seizures.

We sought to characterize the clinical features of tilt-induced psychogenic nonsyncopal collapse (PNSC) from a cohort of young patients and to compare the semiologies between PNSC and EEG-confirmed psychogenic nonepileptic seizures (PNES). A PNSC diagnosis was made if a clinical event occurred during tilt-table testing that the patient regarded as fainting, but neither hypotension nor EEG changes were present. A diagnosis of PNSC was made in 17.6% of all patients referred during the 15-month study period. Cohorts with psychogenic nonsyncopal collapse (n=40) and PNES (n=40) did not differ in age (15.5±2.2 versus 14.6±2.7, p=.11) or female gender (80% versus 72.5%, p=.43). Psychogenic nonsyncopal collapse events were briefer than PNES events (median: 45 versus 201.5s, p<.001). Negative motor signs (head drop, body limpness) predominated in PNSC (85% versus 20%, p<.001), while the positive motor signs of convulsion occurred more often with PNES (90% versus 30%, p<.001). Behavioral arrest (25% versus 32.5%, p=.46) and eye closure (85% versus 72.5%, p=.21) did not differ between PNSC and PNES. Patients with PNSC were more likely to be tearful before (30% versus 7.5%, p=.02) and after (62.5% versus 7.5%, p<.001) an event. In conclusion, although overlap exists, the features of PNSC generally appear similar to neurally mediated syncope, while the features of PNES generally appear similar to epileptic seizures. Psychogenic nonsyncopal collapse and PNES likely represent similar disorders that differ primarily by clinical semiologies and referral patterns.

The Clinical and Electroencephalographic Spectrum of Tilt-Induced Syncope and "Near Syncope" in Youth.

BACKGROUND: The aim of the study was to characterize the clinical and electroencephalographic (EEG) patterns associated with tilt-induced reflex syncope and delayed orthostatic hypotension without syncope in youth. METHODS: We conducted a prospective observational study of 95 patients referred to a pediatric neurology clinic for head-upright tilt testing. Clinical signs, symptoms, video EEG, and continuous blood pressure and heart rate were monitored. RESULTS: Eighty patients had reflex syncope, and 15 had delayed-onset hypotension without syncope. The mean age was 15.3 (standard deviation ±2.3) years; 75 (78.9%) were female. All patients with hypotension only had corresponding signs and symptoms; 13 (86.7%) had corresponding EEG slowing. The duration of EEG slowing with hypotension far exceeded the presyncope interval from onset of slowing to loss of consciousness among patients with syncope (P < 0.001). Although prior near-syncope and presyncope episodes were reported commonly in both groups, patients with delayed hypotension without syncope were less likely to have experienced loss of consciousness during episodes of orthostatic intolerance (P < 0.001). Patients with syncope had either slow-flat-slow (n = 23) or slow-only (n = 57) EEG patterns. Compared to those with slow-only EEG patterns, patients with the slow-flat-slow pattern had greater rates of asystole (P < 0.001), myoclonic movements (P < 0.001), facial grimace (P = 0.003), vocalizations (P = 0.002), and arm flexion (P < 0.001) or extension (P = 0.006) during tilt-induced syncope. CONCLUSIONS: Among otherwise healthy youth, orthostatic signs and symptoms vary across the spectrum of tilt-induced reflex syncope and delayed hypotension without syncope. Delayed hypotension without syncope may represent the poorly defined phenomenon of "near syncope" in some patients.

Sweat patterns differ between tilt-induced reflex syncope and tilt-induced anxiety among youth.

PURPOSE: Profound sweating can occur with reflex-syncope and with emotional distress, but little is known about the similarities and differences between these sweat responses when they occur during orthostatic challenge. We sought to characterize and compare the sweat patterns related to tilt-induced syncope, presyncope, anxiety, and normal tilt testing. METHODS: In a prospective observational study, quantitative sweat rate was measured from the abdomen, forearm, ankle, and thigh during head-upright tilt. Sweat characteristics were compared across tilt diagnoses of syncope, presyncope, anxiety, and normal testing. When anxiety and syncope/presyncope occurred during the same study (separated by ≥6 min), both were diagnosed. RESULTS: Our cohort comprised150 patients (15.1 ± 2.3 years; 82.9 % female) with 156 diagnoses: 76 with reflex-syncope, 31 with presyncope, 23 with anxiety, and 26 with normal results. All syncope/presyncope patients and 20 (87 %) of the anxiety patients had corresponding sweat responses. Minimal or negligible sweating occurred among patients with normal tests. Neither basal sweat (19.4 ± 4.7 versus 18.3 ± 3.7 versus 18.5 ± 3.7 nL/min/cm(2)) nor peak sweat (171 ± 47.4 versus 149.4 ± 64.4 versus 154.4 ± 59.2 nL/min/cm(2)) differed between patients with syncope, presyncope, or anxiety, p = .32 and p = .12, respectively. However, the qualitative sweat patterns related to syncope/presyncope (diffuse, smoothly contoured, symmetrical, single peaks) differed considerably from the sweat patterns related to anxiety (heterogeneous, asymmetrical, roughly contoured single-peak, multi-peak, or progressive sweat changes). CONCLUSIONS: The sweat patterns related to syncope/presyncope are distinguishable from the sweat patterns related to anxiety. Recognition of the different sweat patterns can inform how signs and symptoms are interpreted during clinical orthostatic challenge.

Specific Factors Influence Postconcussion Symptom Duration among Youth Referred to a Sports Concussion Clinic.

OBJECTIVE: To identify the clinical factors that influence the duration of postconcussion symptoms among youth referred to a sports concussion clinic. STUDY DESIGN: A retrospective cohort study was conducted to evaluate several potential predictors of symptom duration via a Cox proportional hazards analyses. The individual postconcussion symptom scores were highly correlated, so these symptoms were analyzed in the statistical model as coefficients derived from principal component analyses. RESULTS: Among 1953 youth with concussion, 1755 (89.9%) had dates of reported symptom resolution. The remainder (10.1%) were lost to follow-up and censored. The median time to recovery was 18 days (range 1-353 days). By 30 days, 72.6% had recovered; by 60 days, 91.4% had recovered; and by 90 days, 96.8% had recovered. Several variables in a multivariate Cox model predicted postconcussion symptom duration: female sex (P < .001, hazard ratio [HR] = 1.28), continued activity participation (P = .02, HR = 1.13), loss of consciousness (P = .03, HR = 1.18), anterograde amnesia (P = .04, HR = 1.15), premorbid headaches (P = .03, HR = 1.15), symptom components from the day of concussion (emotion, P = .03, HR = 1.08), and the day of clinic evaluation (cognitive-fatigue, P < .001, HR = 1.22; cephalalgic, P < .001, HR = 1.27; emotional, P = .05, HR = 1.08; arousal-stimulation, P = .003, HR = 1.1). In univariate analyses, greater symptom scores generally predicted longer symptom durations. Worsening of symptoms from the day of concussion to the day of clinic evaluation also predicted longer recovery (P < .001, HR = 1.59). CONCLUSIONS: Several factors help to predict protracted postconcussion symptom durations among youth referred to a sports concussion clinic.